TEST 37

QId: 2223
Primary renal causes of Nephrotic syndrome

35yoAfrican american
prior heroin abuse.
obese BMI 40kg
exam: decr breath sounds at right lung base
24hr urine shows protein excretion of 7.5g
Q = likely present on kidney biopsy?
A = Focal segmental glomerulosclerosis

a/w HIV, heroin use, morbid obesity

-----
Nephrotic sd (heavy proteinuria >3.5g) w/hypoalbuminemia & edema
Medicine - Renal, Urinary Systems & Electrolytes

QId: 2277
Progressive Multifocal Leukoencephalopathy

epi: JC virus reactivated****

*immunocompr (untreated AIDS) CD4 <200

ss: slow progression, confusion, paresis, ataxia, seizure

dx = CT brain - white matter lesions w/non enhancement/no edema; lumbar puncture (CSF
PCR for JC virus)

tx = often fatal; IF HIV - antiretroviral therapy

----------
wrong:
*MS = inflamed, demyelinating CNS....well-circumscribed (not irregular) white matter lesions.

*cerebral toxoplasma - mc CNS infxn in ppl w/untreated AIDS and causes HA, confusion, fever,
focal deficits = MULTIPLE ring enhanced lesions w/edema

*herpes encephalitis - acute fever, HA, seizures, focal deficits, AMS

Medicine - Infectious Diseases

QId: 2606
Hot Flashes

-Selective Estrogen Receptor Modulators

(Tamoxifen, Raloxifene
*Breast carcinoma hormone receptor-positive
*needle guided biopsy after screening mammogram (Irregular densities)

Q = TAMOXIFEN use.....risk develop?

A = Hot Flashes

1
Indications: Raloxifene: postmenopausal osteoporosis; Tmoxifen: adjuvant treatment for breast
cancer

Side Effect:
*hot flashes
*venous thromboemboli
*Endometrial hyperplasia & carcinoma (tamoxifen only)
Obstetrics & Gynecology - Female Reproductive System & Breast

QId: 3069
WPW: wolff-parkinson white syndrome, accessory pathway - conducts depolarization from atria
to ventricals w/o transversing AV node

Afib occurs in 10-30% ppl w/ WPW

case: 30sM, h/o WPW w/priop episodes Supraventricular Tachycardia

P: irregularly irregular
EKG: atrial fibrillation w/rate of 160/min
Q = next step management?
A = Procainamide

------
wrong:
Medicine - Cardiovascular System

QId: 3208
Dermatomyositis

rash over face; difficulty rising from seated position & climbing stairs.
exam: red rash on upper chest & violaceous periorbital edema present
VS nml.
ex: Symmetrical proximal msk weakness in legs
Q = a/w with which?
A = Malignancy

ss: scaly papules, CPK high.

think possible internal Cancer a/w dermatomyositis (MC: ovarian, lung, pancreas, stomach,
CRC, non-Hodgkin Lymphoma)

-----wrong:
*Inflammatory dz a/w alveolar hemorrhage includes Goodpasture sd, granulomatosis
w/polyangiitis (formerly Wegner's), microscopic polyangiitis, eosinophilic granulomatosis
w/polyangiitis (churg straus), behcet, SLE

*Inflammed dz a/w aortic aneurysms takayasu arteritis, giant cell arteritis, ankylosing spondylitis,
RA, psoriasis arthritis
-----------

2
Medicine - Rheumatology/Orthopedics & Sports

QId: 3661
Muscular Dystrophy - Autosome Dominant

*15yo Teen progressive muscle weakness

*difficulty facial expressions, includes smiling & frowing...
exam: ptosis, temporal wasting, thin cheeks, atrophy of thenar and hypthenar eminences,
TESTICULAR ATROPHY

Myotonia (delayed msk relaxation) - UNABLE to release hand after a handshake (grip myotonia)

Facial weakness, foot drop, dysphagia, heart conduction anomalies

problems include: cataracts, testicular atrophy/infertility, baldness
Pediatrics - Nervous System

QId: 3778
Chronic tophaceous gout.

Q = diagnosis?
A = Gout

Urate crystals....deposit in skin ? tumor formation w/chalky white appearance.

-psoriatic arthritis ss: joint arthritis, asx oligoarthritis, spondyloarthropathy, psoriasis, nail
changes
Medicine - Rheumatology/Orthopedics & Sports

QId: 3867
Precocious Puberty (ss Premature adrenarche: pubic hair; nml bone age)

OBESE secondary sex characteristics is PREMATURE (precocious) in girls <8

boys <9

Obese kids = rf precocious....lots ADIPOSE triggers excess insulin production ? stimulates

adrenal glands to produce sex hormones.

5yo female + pubic hair, bone age nml

Q = diagnosis?
A = Premature adrenarche
------wrong:
*hypothalamic glioma, pituitary hamartoma, idiopathic precocious puberty - causes of central
precocious puberty. SS: advanced bone age, elevated FSH & LH, true precocious development
(breast development)
Pediatrics - Endocrine, Diabetes & Metabolism

3
QId: 3891
Myasthenia Gravis dt ab degradation of ACh receptors @NMJ....ss: fatigue ocular & bulbar msk
weakness

Q = cause of pt's sx?

A = decreased available acetylcholine receptors

most Ach-R antibodies have thymic abnml: thymoma, thymic hyperplasia....appear as anterior
mediastinal mass on chest xray.

ss: difficulty chewing steak. needs eye drops. Upper GI endoscopy & esophageal manometry
are nml. CT scan shown.
--------

Systemic sclerosis = connective tissue dz by fibrosis of skin & visceral organs. GI: involves
causes dysphagia dt fibrous tissue replacement of smooth msk in esophagus

Esophageal manometry shows dysmotility & low LES pressure

---------
Medicine - Nervous System

QId: 4127
Chronic Stable Angina treatment

75yoM
6mo h/o periodic substernal chest pressure....when he walks uphill or climbs 2 flights of stairs.
meds: statin
Treadmill stress test: ST depression leads II, III, avF

given Aspirin, sublingual NG, 3rd med.

Q = this 3rd med acts through which mechanisms?
A = Decreased myocardial contractility
---

BB: first line therapy; ?contractility & HR

CCB: alternative to beta blocker; ?myocardial contractility & HR

Dihydropyridine CCB: added to beta blocker when needed; coronary artery vasodilation,
?afterload by systemic vasodilation

Nitrates: long acting for persistent angina moa: ?preload by dilation of capacitance veins

Ranolazine: for refractory angina; ?Calcium influx

Medicine - Cardiovascular System

QId: 4719
Man collapse in parking lot.
finds no pulse
immediately calls for help

4
Q = important factor for survival?
A = Time to Rhythm analysis and DEFIBRILLATION if indicated

Factors a/w poor outcome after witnessed sudden cardiac arrest

*time elapsed prior to effective resuscitation (delayed bystander CPR, delayed defibrillation)

*initial rhythm of pulseless electrical activity or asystole

*prolonged CPR >5 mins

*Absence of vital signs

*Advanced age
*h/o cardiac disease
*>2 chronic dz
*persistent coma after CPR
*need for intubation or vasopressors
*Pneumonia or renal failure after CPR
*Sepsis, cerebrovascular accident, class 3 or 4 heart failure
Medicine - Cardiovascular System

QId: 12290
Hypovolemia stimulates renin-angiotensin system - helps improve intravascular volume,
glomerular filtration rate, blood pressure via vasoconstriction & kidney-mediated sodium & water
reabsorption
Medicine - Renal, Urinary Systems & Electrolytes

QId: 12343
Pelvic Inflammatory Disease

20sF has RUQ pain.

pain lower abdomen...
RUQ pain increased with deep breathing.
NOW HAS FEVER***, chills, vomiting.
sex active*** w/male partner 102F
examRUQ pain, lower abdomen diffuse tender w/o guarding
Q = likely diagnosis?
A = Pelvic inflammatory disease

ss: lower abdomin pain; abnml bleeding

exam: motion tender; fever >100.9; mucopurulent cervix DC
tx = ceftriax + azithro (or doxy)

intermenstrual spotting.....can spread to abdomen/liver capsule = perihepatitis (Fitz-Hugh Curtis

disease;violin strings)

PID: fever, lower abdomin pain...pleuritic RUQ pain (during inspiration)**

-------
cholecystitis RUQ pain. NO A/W lower abdomin pain; rf: obese/alcohol

5
Viral hepatitis: upper abdomin pain (recent travel to endemic areas) + jaundice, stool color
change

*Perf peptic ulcer = NO FEVER, epigastric pain; NO BOWEL SOUNDS; No guarding/abdomin

rigidity

Ruptured ectopic = NO FEVER; +ve rebound/guarding

Rupture ovarian cyst = DIFFUSE abdomin pain; no fever

Obstetrics & Gynecology - Female Reproductive System & Breast

QId: 12533
Cardiac Tamponade

-cardiac catheterization in ppl w/cardiac tamponade shows elevated & equilibrated intracardiac
diastolic pressures

dx = urgent echocardiogram if suspect Tamponade****

Etio:
-aortic aneurysm or post-MI; cancer, RADIATION therapy; infxn (viral, TB); SLE

ss: beck triade: HoTN, JVD, ?heart sounds; Pulsus paradoxus (SBP ? >10mmHg w/inspiration)

Dx = EKG: ow volt QRS, electrical alternans

CXR: enlarged cardiac silhouette, clear lungs
Echo: Right atrial & ventricular collapse, plethora of IVC

------wrong:
*CT pulmonry angiogram to diagnose: pulmonary embolism; (but LOW or nml) PCWP.... dt
impaired blood flow to lung via left atrium

*Pt has AMS dt HoTN & shock

Surgery - Cardiovascular System

QId: 15047
Reactive Attachment disorder
(develop in young children when ABUSE, Neglect, prolonged institutionalization, inconsistent
care -frequently moving b/n foster homes) disrupts development of a healthy, secure attachment
to caregivers

-kid seldom seek comfort

-doesn't responds to attempts to comfort them
other ss: includes Lack of social responsiveness.

ex: 4yo adjustment to preschool. She was taken way from birth mother, who was abusing coke
& alcohol at age 2...moved to ORPHANAGE***
at home, girl hardly speaks with family and stays in her room.*** HOARDING **** = (neglect)
Q = diagnosis?
A = Reactive attachment disorder

6
(neglect, social withdrawal, lack positive response to attempts to comfort, decr emotional
responsiveness)

----wrong
*adjustment disorder, not diagnosed when pt's ss are better explained by something else

*social & emotional interaction deficit = see in both RAD & Autism.....but if restricted interest,
repetitive motor mannerisms, language impaired = then AUTISM
Pediatrics - Psychiatric/Behavioral & Substance Abuse